Case 3 – Vomiting

You are seeing Frank, a 27 year old homeless male, who was brought into the ER by police because he was found vomiting in a nearby alleyway. Take a history of his complaint. Then, perform a focused physical examination.


  • Onset of vomiting
  • Contents/ appearance of vomitus
  • Blood in vomit
  • Recent alcohol intake
  • Change in bowel habit
  • Association with abdominal pain
  • Severity of abdominal pain
  • Radiation of abdominal pain
  • Association of abdominal pain with position (worse when supine)
  • Fever
  • Relevant social history, including current housing state
  • Alcohol history
  • Assessment for alcohol abuse (CAGE)
  • Drug history
  • Hepatitis status, past vaccination

Physical examination


  • Comments on patient’s overall appearance, including jaundice and muscle wasting
  • Notes any stigmata of chronic liver disease
  • Inspects for masses and bulging flanks
  • Inspects for Cullen’s and Grey Turner’s signs
  • Auscultates in all four quadrants of the abdomen


  • Uses light and deep palpation to examine for tenderness
  • Monitors patient’s reaction to palpation in epigastrum, commenting on guarding
  • Assesses for peritoneal findings, including rebound and shake tenderness
  • Estimates liver span using percussion
  • Palpates for splenomegaly
  • States that they would perform digital rectal examination as part of the abdominal examination

Special Maneuvers

  • Assesses if pain varies with position (comments that pain associated with pancreatitis is somewhat alleviated when patient leans forward)
  • Assesses for asterixis and ascites
Case 3 – Vomiting